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Cerebrovascular Accident CVA

Cerebrovascular Accident CVA. Cerebrovascular Accident. Results from ischemia to a part of the brain or hemorrhage into the brain that results in death of brain cells . Approximately 750,000 in USA annually Third most common cause of death #1 leading cause of disability

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Cerebrovascular Accident CVA

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  1. Cerebrovascular AccidentCVA

  2. Cerebrovascular Accident • Results from ischemia to a part of the brain or hemorrhage into the brain that results in death of brain cells. • Approximately 750,000 in USA annually • Third most common cause of death • #1 leading cause of disability • 25% with initial stroke die within 1 year • 50-75% will be functionally independent • 25% will live with permanent disability • Physical, cognitive, emotional, & financial impact

  3. Cerebrovascular AccidentRisk Factors • Nonmodifiable: • Age – Occurrence doubles each decade >55 years • Gender – Equal for men & women; women die more frequently than men • Race – African Americans, Hispanics, Native Americans, Asian Americans -- higher incidence • Heredity – family history, prior transient ischemic attack, or prior stroke increases risk

  4. Cerebrovascular AccidentRisk Factors Controllable Risks with Medical Treatment & Lifestyle Changes: High blood pressure DiabetesCigarette smoking TIA (Aspirin)High blood cholesterol ObesityHeart Disease Atrial fibrillation Oral contraceptive use Physical inactivity Sickle cell disease Asymptomatic carotid stenosisHypercoagulability

  5. CVA – Risk Factors

  6. Cerebrovascular AccidentAnatomy of Cerebral Circulation • Blood Supply • Anterior: Carotid Arteries – middle & anterior cerebral arteries • frontal, parietal, temporal lobes; basal ganglion; part of the diencephalon (thalamus & hypothalamus) • Posterior: Vertebral Arteries – basilar artery • Mid and lower temporary & occipital lobes, cerebellum, brainstem, & part of the diencephalon • Circle of Willis – connects the anterior & posterior cerebral circulation

  7. Cerebrovascular AccidentAnatomy of Cerebral Circulation • Blood Supply • 20% of cardiac output—750-1000ml/min • >30 second interruption– neurologic metabolism is altered; metabolism stops in 2 minutes; brain cell death < 5 mins.

  8. Cerebrovascular AccidentPathophysiology • Atherosclerosis: major cause of CVA • Thrombus formation & emboli development • Abnormal filtration of lipids in the intimal layer of the arterial wall • Plaque develops & locations of increased turbulence of blood - bifurcations • Increased turbulence of blood or a tortuous area • Calcified plaques rupture or fissure • Platelets & fibrin adhere to the plaque • Narrowing or blockage of an artery by thrombus or emboli • Cerebral Infarction: blocked artery with blood supply cut off beyond the blockage

  9. CVA? • Sudden numbness or weakness of face, arm, or leg especially on one side of the body. • Sudden confusion or trouble speaking or understanding speech. • Sudden trouble seeing in one or both eyes. • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headache with no known cause.

  10. Cerebrovascular AccidentTransient Ischemic Attack • Temporary focal loss of neurologic function • Caused by ischemia of one of the vascular territories of the brain • Micro emboli with temporary blockage of blood flow • Lasts less than 24 hrs – often less than 15 mins • Most resolve within 3 hours • Warning sign of progressive cerebrovascular disease

  11. Cerebrovascular AccidentTransient Ischemic Attack • Diagnosis: • CT without contrast • Confirm that TIA is not related to brain lesions • Cardiac Evaluation • Rule out cardiac mural thrombi • Treatment: • Medications that prevent platelet aggregation • Oral anticoagulants

  12. Cerebrovascular AccidentClassifications Based on underlying pathophysiologic findings

  13. Cerebrovascular AccidentClassifications • Ischemic Stroke • Thrombotic • Embolic • Hemorrhagic Stroke • Intra cerebral Hemorrhage • Subarachnoid Hemorrhage • Aneurysm

  14. Cerebro vascular AccidentClassifications • Ischemic Stroke - inadequate blood flow to the brain from partial or complete occlusions of an artery--85% of all strokes • Extent of a stroke depends on: • Rapidity of onset • Size of the lesion • Presence of collateral circulation • Symptoms may progress in the first 72 hours as infarction & cerebral edema increase • Types of Ischemic Stroke: Thrombotic StrokeEmbolic Stroke

  15. CVA Recognition

  16. Cerebrovascular AccidentIschemic – Thrombotic Stroke • Lumen of the blood vessels narrow – then becomes occluded – infarction • Associated with HTN and Diabetes Mellitus • >60% of strokes • 50% are preceded by TIA • Lacunar Stroke: development of cavity in place of infarcted brain tissue – results in considerable deficits – motor hemiplegia, contralateral loss of sensation or motor ability

  17. Cerebrovascular AccidentIschemic – Embolic Stroke • Embolus lodges in and occludes a cerebral artery • Results in infarction & cerebral edema of the area supplied by the vessel • Second most common cause of stroke – 24% • Emboli originate in endocardial layer of the heart – atrial fibrillation, MI, infective endocarditis, rheumatic heart disease, valvular prostheses • Rapid occurrence with severe symptoms – body does not have time to develop collateral circulation • Any age group • Recurrence common if underlying cause not treated

  18. Cerebrovascular AccidentEmbolic Stroke

  19. Cerebrovascular AccidentGoals for Management • Immediate – assess & stabilize • ABCs, VS • Neurologic screening • Oxygen if hypoxic • IV access • Check glucose • Activate stroke team • 12-lead EKG • Immediate Neuro Assessment • Establish symptom onset • Review hx • Facial droop; arm drift; abnormal speech

  20. Cerebrovascular AccidentGoals for Management • CT Scan – No hemorrhage: • Consider Fibrinolytic therapy • Check for exclusions • rtPA • No anticoagulants or antiplatelet therapy for 24 hours • If not a candidate: Antiplatelet Therapy • CT Scan – Hemorrhage: • Neurosurgery? • If no surgery: Stroke Unit • Monitor BP and treat Hypertension • Monitor Neuro status • Monitor blood glucose and treat as needed • Supportive therapy

  21. Cerebrovascular AccidentGoals for Management • Immediate – assess & stabilize • ABCs, VS • Neurologic screening • Oxygen if hypoxic • IV access • Check glucose • Active stroke team • Emergent CT scan of brain • 12-lead EKG • Immediate Neuro Assessment • Establish symptom onset • Review hx • Stroke Scale • Facial droop; arm drift; abnormal speech

  22. Cerebrovascular AccidentHemorrhagic Stroke • Hemorrhagic Stroke • 15% of all strokes • Result from bleeding into the brain tissue itself • Intracerebral • Subarachnoid

  23. Cerebrovascular AccidentHemorrhage Stroke Intracerebral Hemorrhage • Rupture of a vessel • Hypertension – most important cause • Others: vascular malformations, coagulation disorders, anticoagulation, trauma, brain tumor, ruptured aneurysms • Sudden onset of symptoms with progression • Neurological deficits, headache, nausea, vomiting, decreased LOC, and hypertension • Prognosis: poor – 50% die within weeks • 20% functionally independent at 6 months

  24. Cerebrovascular AccidentHemorrhagic-Subarachnoid • Hemorrhagic Stroke–Subarachnoid Hemorrhage • Intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain

  25. Cerebrovascular AccidentHemorrhagic-Subarachnoid • Commonly caused by rupture of cerebral aneurysm (congenital or acquired) • Saccular or berry – few to 20-30 mm in size • Majority occur in the Circle of Willis • Other causes: Arteriovenous malformation (AVM), trauma, illicit drug abuse • Incidence: 6-16/100,000 • Increases with age and more common in women

  26. Cerebrovascular AccidentHemorrhagic-SubarachnoidCerebral Aneurysm • Warning Symptoms: sudden onset of a severe headache – “worst headache of one’s life” • Change of LOC, Neurological deficits, nausea, vomiting, seizures, stiff neck • Despite improvements in surgical techniques, many patients die or left with significant cognitivedifficulties

  27. Hemorrhagic-SubarachnoidCerebral Aneurysm • Surgical Treatment: • Clipping the aneurysm – prevents rebleed • Coiling – platinum coil inserted into the lumen of the aneurysm to occlude the sac • Postop: Vasospasm prevention – Calcium Channel Blockers

  28. Hemorrhagic-SubarachnoidCerebral Aneurysm – Coiling

  29. Cerebrovascular AccidentClassification

  30. Cerebrovascular AccidentClinical ManifestationsMiddle Cerebral Artery Involvement • Contralateral weakness • Hemiparesis; hemiplegia • Contralateralhemianesthesia • Loss of proprioception, fine touch and localization • Dominant hemisphere: aphasia • Nondominant hemisphere – neglect of opposite side; anosognosia – unaware or denial of neuro deficit • Homonymous hemianopsia – defective vision or blindness right or left halves of visual fields of both eyes

  31. Cerebrovascular AccidentClinical ManifestationsAnterior Cerebral Artery Involvement • Brain stem occlusion • Contralateral • weakness of proximal upper extremity • sensory & motor deficits of lower extremities • Urinary incontinence • Sensory loss (discrimination, proprioception) • Contralateral grasp & sucking reflexes may be present • Apraxia – loss of ability to carry out familiar purposeful movements in the absence of sensory or motor impairment • Personality change: flat affect, loss of spontaneity, loss of interest in surroundings • Cognitive impairment

  32. Cerebrovascular AccidentClinical ManifestationsPosterior Cerebral Artery & Vertebrobasilar Involvement • Alert to comatose • Unilateral or bilateral sensory loss • Contralateral or bilateral weakness • Dysarthria – impaired speech articulation • Dysphagia – difficulty in swallowing • Hoarseness • Ataxia, Vertigo • Unilateral hearing loss • Visual disturbances (blindness, homonymous hemianopsia, nystagmus, diplopia)

  33. Cerebrovascular AccidentClinical Manifestations • Motor Function Impairment • Caused by destruction of motor neurons in the pyramidal pathway (brain to spinal cord) • Mobility • Respiratory function • Swallowing and speech • Gag reflex • Self-care activities

  34. Cerebrovascular AccidentClinical ManifestationsRight Brain – Left Brain Damage

  35. Cerebrovascular AccidentClinical Manifestations • Affect • Difficulty controlling emotions • Exaggerated or unpredictable emotional response • Depression / feelings regarding changed body image and loss of function

  36. Cerebrovascular AccidentClinical Manifestations • Intellectual Function • Memory and judgment • Left-brain stroke: cautious in making judgments • Right-brain stroke: impulsive & moves quickly to decisions • Difficulties in learning new skills

  37. Cerebrovascular AccidentClinical Manifestations • Communication • Left hemisphere dominant for language skills in the right-handed person & most left-handed persons -- Aphasia/Dysphasia • Involvement Expression & Comprehension • Receptive Aphasia (Wernicke’s area): sounds of speech nor its meaning can be understood – spoken & written • Expressive Aphasia (Broca’s area): difficulty in speaking and writing • Dysarthria: Affects the mechanics of speech due to muscle control disturbances – pronunciation, articulation, and phonation

  38. Cerebrovascular AccidentClinical Manifestations • Spatial-Perceptual Alterations – 4 categories: • 1. Incorrect perception of self & illness • 2. Erroneous perception of self in space – may neglect all input from the affected side (worsened by homonymous hemianopsia) • 3. Agnosia: Inability to recognize an object by sight, touch or hearing • 4. Apraxia: Inability to carry out learned sequential movements on command

  39. Cerebrovascular AccidentClinical Manifestations • Elimination • Most problems occur initially and are temporary • One hemisphere stroke: prognosis is excellent for normal bladder function • Bowel elimination: motor control not a problem – constipation associated with immobility, weak abdominal muscles, dehydration, diminished response to the defecation reflex

  40. Cerebrovascular AccidentTreatment Goals • Prevention – Health Maintenance Focus: • Healthy diet • Weight control • Regular exercise • No smoking • Limit alcohol consumption • Route health assessment • Control of risk factors

  41. Cerebrovascular AccidentTreatment Goals • Prevention • Drug Therapy • Surgical Therapy • Rehabilitation

  42. Cerebrovascular AccidentDiagnostic Studies • Done to confirm CVA and identify cause • PE: Neuro Assessment; Carotid bruit • Carotid doppler studies (ultrasound study) • CT – primary – identifies size, location, differentiates between ischemic and hemorrhagic • CTA – CT Angiography – visualizes vasculature • MRI – greater specificity than CT • May not be able to be used on all patients (metal, claustrophobia) • Angiography: gold standard for imaging carotid arteries

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